Timo Hannu

Reactive arthritis following an outbreak of Salmonella typhimurium phage type 193 infection

Objectives: To determine the occurrence and the clinical picture of reactive arthritis (ReA) following an outbreak of Salmonella typhimurium. Methods: An outbreak of S typhimurium phage type DT 193 occurred in several municipalities in Finland in 1999. A questionnaire which had a specific emphasis on musculoskeletal symptoms was mailed to all 78 subjects with a positive stool culture. Based on the answers, all subjects with recent joint complaints were clinically examined or interviewed by telephone. Results: Sixty three of 78 subjects (81%) returned the questionnaire. Of these 63 subjects, five (8%) fulfilled the criteria for ReA. All the five subjects with ReA were adults with oligo- or polyarthritis. The antigen HLA-B27 was positive in two of the four subjects tested. In two of five subjects with ReA, the duration of acute arthritis was over six months. Subjects who had received antimicrobial drugs developed acute musculoskeletal symptoms significantly (p=0.013) less often than those without such treatment. None of the subjects with ReA had received antimicrobial drugs before the onset of joint symptoms. Conclusions: The occurrence of ReA following an outbreak of S typhimurium was at the same level as in outbreaks due to other salmonella serotypes reported previously by us, indicating that the frequency of ReA after various outbreaks is ∼10%. Early use of antimicrobial drugs may prevent the development of musculoskeletal symptoms.

Inflammatory response to acute exposure to welding fumes during the working day

ObjectivesTo investigate cardiorespiratory and inflammatory responses in male workers following exposure to welding fumes and airborne particles in actual workplace conditions.Materials and MethodsWe measured blood leukocytes and their differential counts, platelet count, hemoglobin, sensitive C-reactive protein, fibrinogen, E-selectin, IL-(interleukin)1β, IL-6, IL-8, tumor necrosis factor alpha (TNF-α) and endothelin-1 in blood samples of twenty workers before and after their working day. We also studied peak expiratory flow (PEF), forced expiratory volume in one second (FEV1), and exhaled nitric oxide (NO). We assessed heart rate variability (HRV) by obtaining 24-hour ambulatory electrocardiograms.ResultsThe total blood leukocytes and neutrophils increased after the work shift, whereas IL-1β and E-selectin decreased significantly. There were no statistically significant changes in exhaled NO, FEV1, PEF or HRV.ConclusionOccupational exposure to welding fumes and particles caused a slight, acute inflammatory effect estimated based on the increased values of leukocytes and neutrophils in blood and a decrease in the interleukin 1β and E-selectin values, but no changes in the pulmonary function (exhaled NO, FEV1, PEF) or HRV during the working day were observed.

Non-pharmacological interventions for preventing job loss in workers with inflammatory arthritis

BACKGROUNDnWork participation of patients with inflammatory arthritis (IA) is important not only economically but also for physical and psychological health. There is no Cochrane Review to date on studies of non-pharmacological interventions specifically aimed at preventing job loss in people with IA.nnnOBJECTIVESnTo assess the effects of non-pharmacological interventions that aim to prevent job loss, work absenteeism or improve work functioning for employees with IA (rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis (PsA), other spondylarthritis (SpA) or IA associated with connective tissue diseases, such as Systemic Lupus Erythematosus (SLE)).nnnSEARCH METHODSnWe searched the following databases from inception up to 30 April 2014; The Cochrane Library (including Cochrane Central Register of Controlled Trials, i.e. CENTRAL and DARE), MEDLINE (PubMed), EMBASE (Embase.com), CINAHL (EbSCOhost), ClinicalTrials.gov and PsycINFO (ProQuest). We did not impose language restrictions in the search.nnnSELECTION CRITERIAnWe included randomised controlled trials (RCTs) that evaluated interventions aimed at preventing job loss in adults of working age (18 to 65 years) diagnosed with IA, including RA, AS, PsA, SpA or other types of IA. Primary outcomes were job loss and sickness absenteeism and the secondary outcome was work functioning.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently selected trials for inclusion, extracted data and assessed risk of bias in the included RCTs.nnnMAIN RESULTSnWe included three RCTs with a total of 414 participants at risk of job loss. The majority of participants had IA, most with RA and to a lesser degree AS. The interventions aimed to prevent job loss and improve work functioning in several ways: firstly by evaluating work changes or adaptations and secondly by providing any person-directed interventions including vocational counselling, advice or education. Interventions directly targeted at the work environment were minimal and included workplace visits (one trial) or any actions by an occupational physician (one trial). The duration or dose of the interventions varied from two 1.5-hour sessions (one RCT) over five months, two consultation and multidisciplinary treatments during three months (one RCT), to six to eight individual or group sessions over six months (also one RCT). All participants were recruited through rheumatology clinics, both in or outside hospitals. Included trials investigated job loss (n = two RCTs; 382 participants), work absenteeism and work functioning (n = one RCT; 32 participants). Overall, we evaluated the two smaller trials as having a high risk of bias and the large trial as having a low risk of bias. Trials showed marked differences in how they performed on risk of bias items, particularly on performance bias.We assessed the quality of the evidence using the GRADE approach and judged there to be very low quality evidence across the three reported outcomes. Of the two RCTs investigating job loss, the larger one (n = 242 participants) reported a large statistically significant reduction in job loss (relative risk (RR) = 0.35, 95% confidence interval (CI) 0.18 to 0.68) and the other RCT (n = 140) reported similar effects in both groups, although the CI was very wide (RR = 1.05, 95% CI 0.53 to 2.06). The latter one probably suffered from performance bias and we judged it to have a high risk of bias. The one small trial investigating sickness absenteeism found uncertain results at six months follow-up (MD = -2.42 days, 95% CI -5.03 to 0.19). Finally, in the same small trial investigating work functioning using the Rheumatoid Arthritis-Work Instability Scale (RA-WIS), there was a moderate improvement of intermediate term work functioning (six months; scale range 0 to 23; mean improvement -4.67 points, 95% CI -8.43 to -0.91). We identified no adverse effects in the publications of the three trials.nnnAUTHORS CONCLUSIONSnThis Cochrane review of three RCTs found very low quality evidence overall for job loss prevention interventions having an effect on job loss, work absenteeism and work functioning in workers with inflammatory arthritis. While this review highlights that further high quality RCTs are required, the results suggest that these strategies have potential to be effective.

Reactive arthritis following Salmonella infection: a population-based study

Objectives: To study the incidence and clinical picture of Salmonella-associated reactive arthritis (ReA), as well as other reactive musculoskeletal symptoms and the arthritogenicity of various Salmonella enterica ssp. enterica serotypes in the population. Method: We sent a questionnaire on enteric and extraintestinal (especially musculoskeletal) symptoms to 999 consecutive subjects with a Salmonella-positive stool culture. Analysis of self-reported musculoskeletal symptoms was supplemented with a clinical examination of subjects with recent symptoms. Results: Of the 999 Salmonella-positive subjects, 496 (50%) returned the questionnaire. Of these, 4.4% (22/496) had ReA and 13.7% (68/496) had other reactive musculoskeletal symptoms [tendinitis, enthesopathy, or bursitis (ReTe)]. Among the ReA patients, all adults, Salmonella Enteritidis was the most common causative serotype. The clinical picture of patients with ReA was mostly monoarticular or oligoarticular. Human leucocyte antigen (HLA)-B27 was positive in 42% of patients with ReA. The Salmonella O antigens of the 496 subjects belonged to eight groups (B, C, D1, E, G, I, L, and O), all with different major O antigenic determinants. All 22 patients with ReA and all 68 patients with ReTe were in O antigen groups B, C, D1, or E. However, the occurrence of musculoskeletal complications showed no statistically significant difference in relation to different O antigen groups (p = 0.69). Conclusions: ReA occurred in 4.4% of patients after Salmonella infection, with an annual incidence of 1.8/100 000 in Finland. We found no differences in arthritogenicity between different Salmonella serotypes that trigger musculoskeletal complications.

Systemic inflammatory responses following welding inhalation challenge test

Aim The aim of this study was to investigate inflammatory and respiratory responses to welding fume exposure in patients with suspected occupational asthma. Methods Sixteen patients referred to the Finnish Institute of Occupational Health underwent mild steel (MS) and stainless steel (SS) welding challenge tests, due to suspicion of OA. Platelet count, leucocytes and their differential count, hemoglobin, sensitive CRP, lipids, glucose and fibrinogen were analyzed in addition to interleukin (IL)-1β, IL-6, IL-8, TNF-α, endothelin-1, and E-selectin in plasma samples. Peak expiratory flow (PEF), forced expiratory volume in 1 min (FEV1) and exhaled nitric oxide (NO) measurements were performed before and after the challenge test. Personal particle exposure was assessed using IOM and a mini sampler. Particle size distribution was measured by an Electric Low Pressure Impactor (ELPI). Results The number of leukocytes, neutrophils, and platelets increased significantly, and the hemoglobin level and number of erythrocytes decreased significantly after both the MS and SS exposure tests. Five of the patients were diagnosed with OA, and their maximum fall in FEV1 values was 0.70 l (±0.32) 4 h after SS exposure. MS welding generated an average inhalable particle mass concentration of 31.6, and SS welding of 40.2 mg/m3. The mean particle concentration measured inside the welding face shields by the mini sampler was 30.2 mg/m3 and 41.7 mg/m3, respectively. Conclusions Exposure to MS and SS welding fume resulted in a mild systemic inflammatory response. The particle concentration from the breathing zones correlated with the measurements inside the welding face shields.

Yersinia enterocolitica biotype 1A: a possible new trigger of reactive arthritis

Yersinia enterocolitica (YE) biotype 1A is generally considered non-pathogenic, and the role of it in causing reactive musculoskeletal complications is unclear. We evaluated the capability of YE biotype 1A to induce reactive arthritis (ReA) and other reactive musculoskeletal symptoms. Analysis of self-reported musculoskeletal symptoms was supplemented with a telephone interview (with a permission to acquire copies of patient files from a local physician or hospital) and/or clinical examination of subjects with recent musculoskeletal symptoms after a positive stool culture for YE. The diagnoses of ReA and reactive tendinitis and enthesitis (ReTe) were defined as “definite” when based on clinical examination and/or on interview by phone and “probable” when based solely on the questionnaire. Of 120 subjects, who reported musculoskeletal symptoms, 100 were included in the final analysis. Among these 100 patients, 68% had YE biotype 1A, 16% YE bio/serotype 4, and 1% biotype 2 infection; the remaining 15% had different YE-like strains or a non-biotypable strain. Of the 21 patients with ReA and of the 14 patients with ReTe, the diagnosis was definite in 9 and 7 patients and probable in 12 and 7 patients, respectively. The clinical picture of ReA caused by YE biotype 1A was similar with other bio/serotypes of YE. The definite ReA due to YE biotype 1A occurred in middle-aged adults (5 men, 4 women) with the most frequently affected joints being the knees and ankles. We suggest that YE biotype 1A should be taken into account as a new trigger of ReA.

THU0440 Yersinia Enterocolitica Biotype 1A Infection can Trigger Reactive Arthritis

Background Yersinia enterocolitica (YE) is a well-known trigger of reactive arthritis (ReA) [1]. Studies of YE-related ReA have concentrated on the traditionally pathogenic serotypes O:3 and O:9 (biotypes 4 and 2, respectively) [2, 3]. Biotype 1A is generally considered non-pathogenic [4]. However, biotype 1A has been isolated from stools of diarrheic patients, and the potential pathogenicity of biotype 1A has been discussed in the literature [5, 6]. Objectives To study the capability of YE biotype 1A to induce ReA and other reactive musculoskeletal (MS) symptoms. Methods 406 questionnaires were sent to cases with positive stool culture of YE. Analysis of self-reported MS symptoms was supplemented with a clinical examination of subjects with recent MS symptoms. Results Of the 295 subjects, who returned the questionnaire, 120 reported MS symptoms, of which 114 were included to the final analysis. Among these 114 patients, 77 (68%) had YE biotype 1A, 16 (14%) had YE biotype 4, and one (0.9%) had biotype 2 infection; the remaining 20 (17%) patients had different YE-like strains or had a non-biotypable strain in the stool specimens. Of the subjects, 18% (21/114) fulfilled the criteria for ReA, and a further 12% (14/114) had other reactive MS symptoms (tendinitis or enthesitis). The incidence of ReA was 6% in cases with YE biotype 1 A and 5.4% in cases with biotypes 4 or 2. Conclusions YE biotype 1A can be a causative agent for ReA. Therefore, it should be included among pathogens searched at the diagnostic work up of the aetiology of ReA. References Leirisalo-Repo M. Reactive arthritis. Scand J Rheumatol 2005;34:251-9. Leirisalo M, Skylv G, Kousa M, et al. Followup study on patients with Reiter’s disease and reactive arthritis, with special reference to HLA-B27. Arthritis Rheum 1982;25:249-9. Schiellerup P, Krogfelt KA, Locht H. A comparison of self-reported joint symptoms following infection with different enteric pathogens: effect of HLA-B27.J Rheumatol. 2008;35:480-7. Bottone EJ. Yersinia enterocolitica: the charisma continues. Clin Microbiol Rev 1997;10:257-76. Tennant SM, Grant TH, Robins-Browne RM. Pathogenicity of Yersinia enterocolitica biotype 1A. FEMS Immunol Med Microbiol 2003;38:127-37. Bhagat N, Virdi JS. The enigma of Yersinia enterocolitica biovar 1A. Crit Rev Microbiol 2010;37:1-15. Disclosure of Interest None Declared